Patching the Safety Net

Dr. Scott Haig is an Assistant Clinical Professor of Orthopedic Surgery at Columbia University College of Physicians and Surgeons. He has a private practice in the New York City area. Some patient names have been changed to protect privacy.

Broken arm, painful shoulder, hand, hip or knee? The orthopedic clinic at Columbia Presbyterian Medical Center is a great value. Two orthopedic surgeons, often four or five, will talk to you, examine you (and your x-rays) and then discuss your case in a sophisticated conference and decide on the best course of treatment  all for $45 ($175 if you live outside of the "neighborhood"  what used to be called Spanish Harlem.) I learned a good deal of what I know about treating patients there as a resident, and I've taught there ever since. A few have been there longer, but after twenty years I'm an old-timer. This is a story about another old-timer  a patient named Rosa  who taught me about the perverse incentives of our mixed up health care system.

Dr. Scott Haig is an Assistant Clinical Professor of Orthopedic Surgery at Columbia University College of Physicians and Surgeons. He has a private practice in the New York City area

In 1986 Rosa was a Medicaid mother of three with a painful wrist. In her early twenties, with no husband, on child-support, she was a typical patient from "the neighborhood". Rosa was pretty saucy though; she let you know she didn't like waiting, she was snappy during her interview, she made sure I wrote her out prescriptions for all the medication I recommended, even the over-the-counter ones. This way they would all be paid-for. She spoke no English, and she even poked fun at my clinic Spanish. I made a note of it in her chart.

Two years later I didn't recognize her when I walked into her cubicle in the clinic again. I recognized my handwriting in her chart though. And when she rolled her eyes at my Spanish it all came back. "You've been here three years and you still can't speak Spanish any better?" she accused with a twinkle. Now we got into it: Any better? You've been living in my country all this time and you haven't learned any English? A lively debate on the merits of a bilingual society gave way to a cortisone shot for the same wrist pain. I had our therapists make her a splint and said 'adios'. I liked Rosa.

Moving ahead about five years, I was now clinic Attending  in other words, the boss. "We found your old note on this patient. I think she has DeQuervains (the same wrist problem) again. And could you look at the patient in the next room with me too? I think she has the same thing" The resident was a good one. His report on their histories and physical exams was perfect. He was thinking about operating on both women.

So we went in and said hello to Rosa. We talked as I examined her. What a change! Well-dressed with her hair pulled back tight and carrying a small brief, Rosa had gotten a job. She spoke English decently. She had gotten her kids into a Catholic school. Some magic combination of seeking out a 'better life for my kids' and Welfare reform had helped her make it  though barely. I tried to show off some improved Spanish while explaining the wrist problem. "Give it up doc" was her response. "Just tell me what is the problem and what is to do".

DeQuervains is the most common cause of pain on the thumb-side of the wrist. It's a tendon irritation caused by friction. If it continues to be a problem despite pills, therapy, splints and shots there is a small and simple surgical procedure that cures it. I do the operation under local anesthesia, and because there's a tourniquet with a timer on during the case I can tell you how long it takes: about ten minutes. She understood the explanation and opted for the surgery. Then we went next door.

In the next cubicle was a woman more like the old Rosa  no job, no husband. She had been injected and splinted and was still in pain  though less, I felt, than Rosa. I gave the explanation in Spanish with help from my bilingual resident.

Then we went back out to the control area to discuss the cases and make plans. My resident had made the calls to book the cases. And there in front of the glaring bank of x-ray light boxes we uncovered a dark truth of American medicine  people are penalized for pulling themselves up from poverty, and often receive worse medical care as a result.

Rosa would have to pay over five thousand dollars to have her wrist fixed. The lady behind door number two would get it for free. There were no "doctor's bills" in these prices; the residents are salaried by the hospital, I work the clinic for free and operated on clinic patients gratis. The hospital did, however, accept Medicaid payments. Rosa was now employed  no longer Medicaid eligible  and she had paid $45 for the clinic visit that day. And because she wasn't in any health plan that could strong arm down the hospital bill  they got about $800 for the half-hour use of the 'local room' from HMOs  she was vulnerable to the full-ticket "private fee". Rosa could barely afford the $45 for clinic. She was going to have to live with the pain.

The second lady sailed through without a thought. How unfair, unprogressive and  in the original sense of the word  un-American, was the way in which Rosa was penalized by our system for doing well. So here's the issue: We need a medical safety net that does not punish people for doing good things like earning their own living and taking care of their children.

So here's my solution:

1. Two years of mandatory public health service for all docs leaving their residencies or fellowships.

These are fully trained physicians, about to go into practice on their own. They have less responsibility at this point than they will ever have again in their lives, and they want experience. They are younger and hopefully have as great a sense of mission as they ever will. It is a closed-ended commitment. They will probably look back on the two years as some of the best in their lives, even though they will be paid like nurses. Older docs and nurses can volunteer to work alongside or supervise, though they will not be paid  and as a result, should not be able to be sued. They will work through city hospitals, the VA system and any others that welcome the idea of pro bono work. They will take care of anyone whose income puts them in the bottom 20% of the country.

2. Absolute suspension of the malpractice threat for doctors and nurses and hospitals doing charity work.

Nothing stifles altruism more than the threat of losing your house and life-savings; even just having to deal with a suit is enough to stop most docs from giving free care. What is the downside of this? We lose the ability to sue doctors, nurses and hospitals doing charity work. The upside? We release a huge wave of volunteerism among docs and we make medical care more efficient and less expensive. Does it really make sense that docs and nurses who give their time and skill taking care of poor people for free actually have some desire to experiment on or simply torture their patients? Not being able to cash in on the malpractice bonanza is the price of free medical care. It's a bargain.

3. Administration in the charity hospitals will be done or supervised by doctors answering to doctors. For very little money or for free.

Federal and state regulatory packages like HIPPA, JCAH accreditation and many other chart-stuffing bureaucratic drags on the system will be suspended. Anyone who was there knows this: hospitals were cheaper, ran better and had more patients in them 35 years ago  before all the agencies and laws.

Plenty of details certainly remain, but this much is certain: putting up the safety net is only a matter of good organization. We have more money and more medical know-how than any group at any time, anywhere in the world. Rosa made me realize what a copout I accept; how cowardly it is to throw up hands and and complain about the "system". But don't feel too bad for her. We actually did get her in to have her wrist fixed  for free  eventually. It took a few tricks that I'm not about to reveal. But the fact that we had to go to such questionable lengths to make sure Rosa could be rewarded, rather than punished, for improving her lot in life, shows that our current health care system needs some radical surgery.